NURS 6512 Week 7 Focused Exam: Chest Pain Brian Foster Results

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NURS 6512 Week 7 Focused Exam Chest Pain Brian Foster Results

NURS 6512 Week 7 Focused Exam: Chest Pain Brian Foster Results

Experience Overview

Patient: Brian Foster

NURS 6512 Week 7 Focused Exam: Chest Pain Brian Foster Results

Digital Clinical Experience Score

99.1%

This score measures your performance on the Student Performance Index in relation to other students in comparable academic programs. Your instructor has chosen to scale your Student Performance Index score so that the average score on the index is 80.0%. This score may not be your final grade if your instructor chooses to include additional components, such as documentation or time spent.

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Student Performance Index

67

out of

69

Proficiency Level:

Proficient
Students rated as “proficient” demonstrate an entry-level expertise in advanced practice competencies and clinical reasoning skills. In comparable programs, the top 25% of students perform at the level of a proficient practitioner.

Subjective Data Collection

30

out of

30

Objective Data Collection

31

out of

33

Education and Empathy

6

out of

6

Time

602 minutes total spent in assignment

Interaction with patient

602 minutes

Transcript

Started: Oct 05, 2020 | Total Time: 602 min
Your avatar
Hi Mr Foster, My name is , I am going to examine you today.

Greet
10/05/20 1:18 PM MDT

Brian Foster
Good morning.
Your avatar
What brought you here today ?

Question
10/05/20 1:18 PM MDT

Brian Foster
I have been having some troubling chest pain in my chest now and then for the past month.
Your avatar
Oh I’m sorry to hear that, it should be very uncomfortable to have that pain for a whole month.

Empathize
10/05/20 1:22 PM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
? (No matching questions found.)

Question
10/05/20 1:22 PM MDT

Your avatar
What is the onset of your pain ?

Question
10/05/20 1:23 PM MDT

Brian Foster
I first noticed it earlier this month. I thought it might just be heartburn and it passed after about a couple of minutes.
Your avatar
What is the exact location of the pain ?

Question
10/05/20 1:24 PM MDT

Brian Foster
When the pain happens, I feel it mostly in the middle of my chest, over my heart.
Your avatar
When did you chest pain start ?

Question
10/05/20 1:25 PM MDT

Brian Foster
I first noticed it earlier this month. I thought it might just be heartburn and it passed after a couple of minutes.
Your avatar
What is the exact location of the pain ?

Question
10/05/20 1:25 PM MDT

Brian Foster
When the pain happens, I feel it mostly in the middle of my chest, over my heart.
Your avatar
Sorry to hear that

Empathize
10/05/20 1:26 PM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
Easter pain radiates anywhere ? (Clarified to Is your pain radiating?.)

Question
10/05/20 1:26 PM MDT

Brian Foster
The pain doesn’t radiate anywhere. It’s mostly just right in the middle of my chest. (Clarified to if the pain is radiating.)
Your avatar
If your arm hurts (Clarified to Do you have pain in your arm?.)

Question
10/05/20 1:26 PM MDT

Brian Foster
No, when I am having the chest pain, it’s mostly just in middle of my chest. (Clarified to if I have pain in my arm.)
Your avatar
Do you have a pain in your shoulder ?

Question
10/05/20 1:27 PM MDT

Brian Foster
No, the pain hasn’t been in my shoulder.
Your avatar
Do you have a back pain ?

Question
10/05/20 1:27 PM MDT

Brian Foster
I haven’t had back pain, no.
Your avatar
Can you tell me the duration of the pain ? (No matching questions found.)

Question
10/05/20 1:28 PM MDT

Your avatar
Can you describe the duration of the pain ? (Clarified to Can you tell me what the pain is like?.)

Question
10/05/20 1:28 PM MDT

Brian Foster
Well, it mostly feels tight and uncomfortable right in the middle of my chest. (Clarified to if I can tell you what the pain is like.)
Your avatar
How often pain occurs ? (Clarified to How often do you have pain?.)

Question
10/05/20 1:29 PM MDT

Brian Foster
Well, it has happened three times the past month. It usually goes away after about a couple of minutes. (Clarified to how often I have pain.)
Your avatar
Can you describe your pain from 0 to 10 scale ?

Question
10/05/20 1:29 PM MDT

Brian Foster
I’d say maybe a . . . 5? It’s just really uncomfortable . . . like there’s nothing I can do about it. Right now it’s like a zero though.
Your avatar
Sorry to hear that

Empathize
10/05/20 1:30 PM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
Can you describe your pain ?

Question
10/05/20 1:31 PM MDT

Brian Foster
Well, it mostly feels tight and uncomfortable right in the middle of my chest.
Your avatar
ASA pain crashing ? (Clarified to Do you take aspirin?.)

Question
10/05/20 1:31 PM MDT

Brian Foster
I usually just take Tylenol or ibuprofen. (Clarified to if I take aspirin.)
Your avatar
What is the dosage of Tylenol are you taking ?

Question
10/05/20 2:35 PM MDT

Brian Foster
Just whatever the bottle recommends for an adult.
Your avatar
What is the dosage of ibuprofen you taking ? (Clarified to What is the strength of the ibuprofen you take?.)

Question
10/05/20 2:35 PM MDT

Brian Foster
Just whatever the bottle recommends for an adult. (Clarified to What strength ibuprofen I take.)
Your avatar
Is it Tylenol helps ?

Question
10/05/20 2:35 PM MDT

Brian Foster
Just a couple when I get a headache, which is not very often.
Your avatar
How often do you take Tylenol ?

Question
10/05/20 2:36 PM MDT

Brian Foster
I took some today . . . maybe every couple days for mild pain.
Your avatar
What is the reason you’re taking ibuprofen ?

Question
10/05/20 2:36 PM MDT

Brian Foster
Just when I need it for various aches and pains. Probably not more than 3 or 4 times a month.
Your avatar
Where else do you have a pain ?

Question
10/05/20 2:36 PM MDT

Brian Foster
No, when I am having the chest pain, it’s mostly just in middle of my chest.
Your avatar
Do you have a pain somewhere else in your body ?

Question
10/05/20 2:37 PM MDT

Brian Foster
No, when I am having the chest pain, it’s mostly just in middle of my chest.
Your avatar
What is the aggravating factors ? (Clarified to Are there any aggravating factors?.)

Question
10/05/20 2:37 PM MDT

Brian Foster
Well, the pain seems to start when I’m doing something physical . . . the first time it happened while I was doing yard work, and the second time . . . I had to take the stairs at work because the elevator broke. Both times it got better if I took a break or sat down to rest. (Clarified to if there are aggravating factors.)
Your avatar
What activity triggers pain ?

Question
10/05/20 2:39 PM MDT

Brian Foster
If I’m up and moving around I definitely notice it more and it makes me feel like I should sit down and take a deep breath or something.
Your avatar
He’s a pain worse when you eat ?

Question
10/05/20 2:40 PM MDT

Brian Foster
I don’t think eating has anything to do with it. One episode did happen when my wife and I were out for dinner, but it seemed to happen before we even settled. The episodes don’t seem all that related, to be honest.
Your avatar
It can be a lot of triggers in your diet which would aggravate and trigger your pain Mr.Foster.

Educate
10/05/20 2:43 PM MDT

Brian Foster
Good to know. Thank you.
Your avatar
Do you like spicy food ?

Question
10/05/20 2:43 PM MDT

Brian Foster
Sure, I like spicy food. I don’t eat it very often, though. Maybe once or twice a month.
Your avatar
Do you like high-fat food ? (Clarified to Do fatty foods cause the pain?.)

Question
10/05/20 2:44 PM MDT

Brian Foster
I don’t think that has anything to do with it, but I guess I don’t know. (Clarified to if fatty foods cause the pain.)
Your avatar
What relieves your pain ?

Question
10/05/20 2:44 PM MDT

Brian Foster
I’m not sure. I think lying still seems to help a little.
Your avatar
Take anything for chest pain ?

Question
10/05/20 2:46 PM MDT

Brian Foster
No, not yet.
Your avatar
Do you take medication for hypertension ?

Question
10/05/20 2:46 PM MDT

Brian Foster
I take metoprolol, yes. [AUDIO COMING SOON]
Your avatar
Is a dosage of Metoprolol ? (Clarified to What dose of Lopressor do you take?.)

Question
10/05/20 2:47 PM MDT

Brian Foster
I think it’s 100 mg, once a day. (Clarified to what dose of Lopressor I take.)
Your avatar
Do you take any medication for hyperlipidemia ?

Question
10/05/20 2:47 PM MDT

Brian Foster
I take atorvastatin. [AUDIO COMING SOON]
Your avatar
What is the dosage of atorvastatin are you taking ?

Question
10/05/20 2:48 PM MDT

Brian Foster
I think it’s twenty milligrams a day.
Your avatar
Do you take over-the-counter medications ?

Question
10/05/20 2:48 PM MDT

Brian Foster
Oh, just ibuprofen or Tylenol occasionally for pain.
Your avatar
Do you take any supplements ?

Question
10/05/20 2:48 PM MDT

Brian Foster
I take fish oil, that’s it.
Your avatar
How frequently you take medication for hyperlipidemia ? (Clarified to Do you take cholesterol medication?.)

Question
10/05/20 2:49 PM MDT

Brian Foster
I take atorvastatin. [AUDIO COMING SOON] (Clarified to if I take cholesterol medication.)
Your avatar
How often do you take atorvastatin ?

Question
10/05/20 2:50 PM MDT

Brian Foster
I take them daily. I’m pretty good about following the doctor’s orders.
Your avatar
When have you been diagnosed with high blood pressure ?

Question
10/05/20 2:51 PM MDT

Brian Foster
Yes, I supposedly have moderately high blood pressure.
Your avatar
When you started to take metoprolol ?

Question
10/05/20 2:51 PM MDT

Brian Foster
I think it’s been about one year.
Your avatar
When have you been diagnosed with hyperlipidemia ? (Clarified to Do you have an anxiety disorder?.)

Question
10/05/20 2:51 PM MDT

Brian Foster
I’ve never had any anxiety problems before. [AUDIO COMING SOON] (Clarified to if I have an anxiety disorder.)
Your avatar
When have you been diagnosed with hyperlipidemia ? (Clarified to Are you diagnosed with high blood pressure?.)

Question
10/05/20 2:52 PM MDT

Brian Foster
Yes, I supposedly have moderately high blood pressure. (Clarified to if I have been diagnosed with hypertension.)
Your avatar
I’m sorry to hear that

Empathize
10/05/20 2:52 PM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
Do you do exercise ?

Question
10/05/20 2:53 PM MDT

Brian Foster
Well I used to ride my bike a lot but it got stolen a couple years ago. I guess I haven’t had much regular exercise since then. I want to get a new bike if the doctor says it is OK to exercise with this chest pain I’ve been having.
Your avatar
I’m sorry to hear that your bike was stolen

Empathize
10/05/20 2:53 PM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
When did the exercise last time ?

Question
10/05/20 2:53 PM MDT

Brian Foster
Well I used to ride my bike a lot but it got stolen a couple years ago. I guess I haven’t had much regular exercise since then. I want to get a new bike if the doctor says it is OK to exercise with this chest pain I’ve been having.
Your avatar
What type of food do you like ?

Question
10/05/20 2:54 PM MDT

Brian Foster
Um, let’s see . . . For breakfast I usually eat a granola bar and drink an instant breakfast shake. I’ve been doing that a while since it saves time in the morning. Most days for lunch I get a sandwich from the sub shop near work. That’s usually a turkey sub, but sometimes I get a spicy Italian sub. My wife and I grill a lot, and usually have some grilled meat with veggies for dinner.
Your avatar
United include a lot of processed and fast food which is not good for your body. To have the same fast food diet may affect you over the time. You need to change your diet.

Educate
10/05/20 2:57 PM MDT

Brian Foster
Good to know. Thank you.
Your avatar
You need to exercise.Not essential to do that with a bike. You can do sit ups, running or just simple indoor exercises in your home.

Educate
10/05/20 2:59 PM MDT

Brian Foster
Good to know. Thank you.
Your avatar
Did you lose any weight ? (Clarified to Have you lost weight?.)

Question
10/05/20 2:59 PM MDT

Brian Foster
Not exactly . . . I’ve gained about fifteen to twenty pounds in the last couple years. (Clarified to if I have lost weight.)
Your avatar
It’s not good to gain the weight. You need to change the diet and start doing the exercises.

Educate
10/05/20 3:10 PM MDT

Brian Foster
Good to know. Thank you.
Your avatar
What’s what’s your fathers health ?

Question
10/05/20 3:14 PM MDT

Brian Foster
He really wasn’t doing so great in the last few years. He died when he was 75 of colon cancer, but even before that, his weight and his blood pressure and cholesterol were getting the best of him. It was rough. He didn’t last too long after the cancer diagnosis, unfortunately. I think he was tired of fighting.
Your avatar
I’m sorry to hear that it should be very difficult to lose the father

Empathize
10/05/20 3:15 PM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
How did you cope with a losing father ? (No matching questions found.)

Question
10/05/20 3:15 PM MDT

Your avatar
How did you cope after you lost your father ?

Question
10/05/20 3:16 PM MDT

Brian Foster
Yeah. He died of colon cancer. He also had high blood pressure and high cholesterol.
Your avatar
Sorry to hear that

Empathize
10/05/20 3:16 PM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
Who’s your mother’s health ?

Question
10/05/20 3:16 PM MDT

Brian Foster
She has type 2 diabetes and some high blood pressure, but I think she’s doing pretty well for 80.
Your avatar
Do you have a brothers and sisters ?

Question
10/05/20 3:17 PM MDT

Brian Foster
I have a sister, and I had a brother but he died many years ago.
Your avatar
Sorry to hear that

Empathize
10/05/20 3:17 PM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
How was your maternal grandmother ? (Clarified to How is the health of your maternal grandmother?.)

Question
10/05/20 3:17 PM MDT

Brian Foster
She had breast cancer. She was in her 60s when she died. (Clarified to how my maternal grandmother’s health is.)
Your avatar
About maternal grandfather ?

Question
10/05/20 3:18 PM MDT

Brian Foster
My grandfather on my mom’s side died of a heart attack. He was in his mid-fifties.
Your avatar
Sorry to hear that

Empathize
10/05/20 3:18 PM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
How is your paternal grandfather ?

Question
10/05/20 3:18 PM MDT

Brian Foster
He was healthy right up until he died. He went in his sleep at 85, and we just called it old age.
Your avatar
Sorry to hear that

Empathize
10/05/20 3:19 PM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
How about fraternal grandmother ? (No matching questions found.)

Question
10/05/20 3:19 PM MDT

Your avatar
How about paternal grandmother ?

Question
10/05/20 3:19 PM MDT

Brian Foster
She died of pneumonia when she was almost 80. 78 or 79, I think.
Your avatar
Sorry to hear that

Empathize
10/05/20 3:20 PM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
Do you have children ?

Question
10/05/20 3:20 PM MDT

Brian Foster
Yes, I have two great kids. Well, they’re not kids. Sam is 26 and Allie is 19.
Your avatar
Does it have any medical conditions ?

Question
10/05/20 3:20 PM MDT

Brian Foster
The doctors told me I have a little bit of high blood pressure and cholesterol, but that’s it.
Your avatar
Is your daughter healthy ?

Question
10/05/20 3:21 PM MDT

Brian Foster
Allie’s doing great. She has asthma, but she’s got a handle on it. [AUDIO COMING SOON]
Your avatar
How is your son doing ?

Question
10/05/20 3:21 PM MDT

Brian Foster
He’s 26.
Your avatar
Do you smoke ?

Question
10/05/20 3:21 PM MDT

Brian Foster
Nope, I had a lot of friends who did but I never started.
Your avatar
Do you drink ?

Question
10/05/20 3:21 PM MDT

Brian Foster
Sure, but never more than two or three beers on a weekend.
Your avatar
Do you do drugs ?

Question
10/05/20 3:22 PM MDT

Brian Foster
Nope.
Your avatar
Do you have any hobby ?

Question
10/05/20 3:22 PM MDT

Brian Foster
I like to fish, I like sports . . . let’s see, I do some small electronics repair sometimes, and I go to my son’s bodybuilding competitions when I can.
Your avatar
Did you have any surgeries ?

Question
10/05/20 3:23 PM MDT

Brian Foster
I’ve never had any surgeries.
Your avatar
It is very good that you dont have any surgeries

Empathize
10/05/20 3:23 PM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
Do you have any allergy ?

Question
10/05/20 3:24 PM MDT

Brian Foster
No, well . . . I’ve had a bad reaction to codeine before, but that is all I know of.
Your avatar
What type of reaction do you have to codeine ?

Question
10/05/20 3:24 PM MDT

Brian Foster
It makes me nauseous and I vomit.
Your avatar
How was your immunizations ? (Clarified to What immunizations have you had?.)

Question
10/05/20 3:25 PM MDT

Brian Foster
I don’t remember exactly . . . maybe it’s on my chart. (Clarified to what vaccines I have had.)
Your avatar
She hasn’t been told that your cholesterol is always high ?

Question
10/06/20 6:29 AM MDT

Brian Foster
I’ve been told it’s moderately high. I’ve never noticed any actual symptoms from that though.
Your avatar
Have you been tested for diabetes ?

Question
10/06/20 6:29 AM MDT

Brian Foster
My mom and my sister both have diabetes, but I don’t have it.
Your avatar
Have you been monitoring your blood pressure ?

Question
10/06/20 6:29 AM MDT

Brian Foster
Not usually. They check it when I get checkups. My doctor has never seemed overly concerned about it.
Your avatar
Do you remember your last blood pressure reading ? (Clarified to Do you know your blood pressure number?.)

Question
10/06/20 6:30 AM MDT

Brian Foster
No, not offhand. (Clarified to if I know my blood pressure number.)
Your avatar
You need to monitor your blood pressure and you need to know your Baseline.

Educate
10/06/20 6:30 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
Have you done any EKG recently ? (No matching questions found.)

Question
10/06/20 6:31 AM MDT

Your avatar
Did your doctor do any EKG ? (No matching questions found.)

Question
10/06/20 6:31 AM MDT

Your avatar
Any electrocardiogram ? (No matching questions found.)

Question
10/06/20 6:32 AM MDT

Your avatar
EKG done ? (Clarified to When was your last EKG?.)

Question
10/06/20 6:32 AM MDT

Brian Foster
I had one about three months ago. They usually put one on me at my annual physical. (Clarified to when my last EKG was.)
Your avatar
Well, EKG shows your heart monitoring, it will give us an idea how is your heart works.

Educate
10/06/20 6:34 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
What was the result of EKG ?

Question
10/06/20 6:34 AM MDT

Brian Foster
I don’t remember the actual results, but as far as I know, it was normal.
Your avatar
Do you have a primary care provider ?

Question
10/06/20 6:34 AM MDT

Brian Foster
Dr. Melinda Smith.
Your avatar
It is Good that you have one.

Educate
10/06/20 6:35 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
When your last visit your primary care provider ?

Question
10/06/20 6:35 AM MDT

Brian Foster
I had a physical about 3 months ago.
Your avatar
Do you have stress ?

Question
10/06/20 6:36 AM MDT

Brian Foster
Not usually, but I’m feeling pretty anxious not knowing what’s going on with my chest.
Your avatar
I’m sorry to hear that

Empathize
10/06/20 6:36 AM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
Do your exercise ?

Question
10/06/20 6:37 AM MDT

Brian Foster
Well I used to ride my bike a lot but it got stolen a couple years ago. I guess I haven’t had much regular exercise since then. I want to get a new bike if the doctor says it is OK to exercise with this chest pain I’ve been having.
Your avatar
I’m sorry that chest pain makes you not exercise

Empathize
10/06/20 6:37 AM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
Do you drink water regularly ?

Question
10/06/20 6:37 AM MDT

Brian Foster
I usually drink water all day at work. At least four glasses, probably more. [AUDIO COMING SOON]
Your avatar
Let’s go to take water

Educate
10/06/20 6:38 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
Do you drink alcohol ?

Question
10/06/20 6:39 AM MDT

Brian Foster
Sure, but never more than two or three beers on a weekend.
Your avatar
That’s moderate drinking

Educate
10/06/20 6:39 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
Do you have a fever ?

Question
10/06/20 6:40 AM MDT

Brian Foster
I haven’t had a fever, no.
Your avatar
They have a chills ?

Question
10/06/20 6:40 AM MDT

Brian Foster
I haven’t had chills, no.
Your avatar
Do you have fatigue ?

Question
10/06/20 6:40 AM MDT

Brian Foster
I’m not more tired than normal.
Your avatar
Do you have night sweats ?

Question
10/06/20 6:41 AM MDT

Brian Foster
Nope, no night sweats.
Your avatar
Do you have thought the dacianpalpitations ?

Question
10/06/20 6:41 AM MDT

Brian Foster
Nah, I don’t think about stuff like that. I’m happy with my life.
Your avatar
Do you have palpitations ?

Question
10/06/20 6:41 AM MDT

Brian Foster
I don’t think so. I haven’t noticed any.
Your avatar
Do you have angina ?

Question
10/06/20 6:42 AM MDT

Brian Foster
I’ve never been diagnosed with angina. [AUDIO COMING SOON]
Your avatar
Have you ever had edema ?

Question
10/06/20 6:42 AM MDT

Brian Foster
I haven’t noticed any swelling.
Your avatar
Have you had any blood clots ?

Question
10/06/20 6:42 AM MDT

Brian Foster
Not that I know of.
Your avatar
Any history of rheumatic fever ?

Question
10/06/20 6:43 AM MDT

Brian Foster
No, I never had that.
Your avatar
Any history of heart murmur ?

Question
10/06/20 6:43 AM MDT

Brian Foster
No, none that I know of.
Your avatar
? (No matching questions found.)

Question
10/06/20 6:43 AM MDT

Your avatar
Do you have a cough ?

Question
10/06/20 6:43 AM MDT

Brian Foster
I don’t have a cough.
Your avatar
Do you have difficulty breathing ?

Question
10/06/20 6:44 AM MDT

Brian Foster
My breathing’s fine.
Your avatar
Do you have sore throat ?

Question
10/06/20 6:44 AM MDT

Brian Foster
I haven’t had a sore throat in a long time.
Your avatar
Do you have change in sense of taste ?

Question
10/06/20 6:45 AM MDT

Brian Foster
I can still taste things fine.
Your avatar
Do you have any dysphasia ? (No matching questions found.)

Question
10/06/20 6:45 AM MDT

Your avatar
Do you have problem with swallowing ?

Question
10/06/20 6:45 AM MDT

Brian Foster
I haven’t had any trouble swallowing.
Your avatar
Do you have nausea ?

Question
10/06/20 6:45 AM MDT

Brian Foster
No, I haven’t felt nauseous. I just had pain in my chest.
Your avatar
Do you have diarrhea ?

Question
10/06/20 6:46 AM MDT

Brian Foster
I have, but it is very rare for me.
Your avatar
Do you have constipation ?

Question
10/06/20 6:46 AM MDT

Brian Foster
I haven’t had problems with that. I wish it were only that.
Your avatar
Do you have any family history of heart attack ?

Question
10/06/20 6:46 AM MDT

Brian Foster
Well, my mom’s dad died of a heart attack. He was pretty young too.
Your avatar
Do you have a family history of a stroke ?

Question
10/06/20 6:47 AM MDT

Brian Foster
No, none that I know of.
Your avatar
 Measured vitals

Exam Action
10/06/20 6:49 AM MDT

Your avatar
Mr. Foster, Thank you for answering my questions now I’m going to do physical examination

Educate
10/06/20 6:49 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
 Tested blood pressure in left arm with cuff

Exam Action
10/06/20 6:51 AM MDT

Your avatar
 Tested blood pressure in right arm with cuff

Exam Action
10/06/20 6:51 AM MDT

Your avatar
 Measured vitals

Exam Action
10/06/20 6:51 AM MDT

Your avatar
 Inspected face

Exam Action
10/06/20 6:51 AM MDT

Your avatar
 Inspected for jugular venous distension: No jugular venous distention; JVP 3 cm above sternal angle

Exam Action
10/06/20 6:52 AM MDT

Your avatar
 Inspected anterior chest wall

Exam Action
10/06/20 6:52 AM MDT

Your avatar
 Inspected left side of abdomen

Exam Action
10/06/20 6:53 AM MDT

Your avatar
 Inspected front of abdomen

Exam Action
10/06/20 6:53 AM MDT

Your avatar
 Inspected left side of abdomen

Exam Action
10/06/20 6:53 AM MDT

Your avatar
 Inspected right hand: no visible abnormal findings

Exam Action
10/06/20 6:54 AM MDT

Your avatar
 Inspected left hand: no visible abnormal findings

Exam Action
10/06/20 6:54 AM MDT

Your avatar
 Inspected fingernails of right hand

Exam Action
10/06/20 6:55 AM MDT

Your avatar
 Inspected fingernails of left hand

Exam Action
10/06/20 6:55 AM MDT

Your avatar
 Inspected left leg

Exam Action
10/06/20 6:56 AM MDT

Your avatar
 Inspected right leg

Exam Action
10/06/20 6:56 AM MDT

Your avatar
 Inspected toenails on left foot

Exam Action
10/06/20 6:56 AM MDT

Your avatar
 Inspected toenails on right foot

Exam Action
10/06/20 6:57 AM MDT

Your avatar
 Inspected left leg

Exam Action
10/06/20 6:57 AM MDT

Your avatar
 Inspected right leg

Exam Action
10/06/20 6:57 AM MDT

Your avatar
 Inspected right leg for edema: No edema

Exam Action
10/06/20 6:58 AM MDT

Your avatar
 Inspected left leg for edema: No edema

Exam Action
10/06/20 6:58 AM MDT

Your avatar
 Checked capillary refill in fingernails

Exam Action
10/06/20 6:58 AM MDT

Your avatar
 Checked capillary refill in fingernails

Exam Action
10/06/20 6:58 AM MDT

Your avatar
 Checked capillary refill in fingernails

Exam Action
10/06/20 6:58 AM MDT

Your avatar
 Checked capillary refill in fingernails

Exam Action
10/06/20 6:58 AM MDT

Your avatar
 Checked capillary refill in fingernails

Exam Action
10/06/20 6:59 AM MDT

Your avatar
 Checked capillary refill in fingernails

Exam Action
10/06/20 6:59 AM MDT

Your avatar
 Checked capillary refill in fingernails

Exam Action
10/06/20 6:59 AM MDT

Your avatar
 Auscultated right carotid pulse: Bruit present

Exam Action
10/06/20 6:59 AM MDT

Your avatar
 Auscultated left carotid pulse

Exam Action
10/06/20 6:59 AM MDT

Your avatar
 Auscultated right carotid pulse: Bruit present

Exam Action
10/06/20 6:59 AM MDT

Your avatar
 Auscultated left carotid pulse

Exam Action
10/06/20 7:00 AM MDT

Your avatar
 Auscultated right carotid pulse: Bruit present

Exam Action
10/06/20 7:00 AM MDT

Your avatar
 Auscultated aortic area with the bell

Exam Action
10/06/20 7:01 AM MDT

Your avatar
 Auscultated pulmonic area with the bell

Exam Action
10/06/20 7:01 AM MDT

Your avatar
 Auscultated Erb’s point with the bell

Exam Action
10/06/20 7:01 AM MDT

Your avatar
 Auscultated tricuspid area with the bell

Exam Action
10/06/20 7:01 AM MDT

Your avatar
 Auscultated mitral area with the bell

Exam Action
10/06/20 7:01 AM MDT

Your avatar
 Auscultated breath sounds in anterior right upper lobe

Exam Action
10/06/20 7:02 AM MDT

Your avatar
 Auscultated breath sounds in anterior left upper lobe

Exam Action
10/06/20 7:02 AM MDT

Your avatar
 Auscultated breath sounds in anterior right middle lobe

Exam Action
10/06/20 7:02 AM MDT

Your avatar
 Auscultated breath sounds in anterior left mid-chest (upper lobe)

Exam Action
10/06/20 7:02 AM MDT

Your avatar
 Auscultated breath sounds in anterior right lower lobe

Exam Action
10/06/20 7:02 AM MDT

Your avatar
 Auscultated breath sounds in anterior left lower lobe

Exam Action
10/06/20 7:02 AM MDT

Your avatar
 Auscultated aorta in abdomen

Exam Action
10/06/20 7:03 AM MDT

Your avatar
 Auscultated right renal pulse

Exam Action
10/06/20 7:03 AM MDT

Your avatar
 Auscultated left renal pulse

Exam Action
10/06/20 7:04 AM MDT

Your avatar
 Auscultated right iliac pulse

Exam Action
10/06/20 7:04 AM MDT

Your avatar
 Auscultated left iliac pulse

Exam Action
10/06/20 7:04 AM MDT

Your avatar
 Auscultated left femoral pulse

Exam Action
10/06/20 7:04 AM MDT

Your avatar
 Auscultated right femoral pulse

Exam Action
10/06/20 7:04 AM MDT

Your avatar
 Auscultated right upper quadrant

Exam Action
10/06/20 7:04 AM MDT

Your avatar
 Auscultated left upper quadrant

Exam Action
10/06/20 7:04 AM MDT

Your avatar
 Auscultated left lower quadrant

Exam Action
10/06/20 7:04 AM MDT

Your avatar
 Auscultated right lower quadrant

Exam Action
10/06/20 7:04 AM MDT

Your avatar
 Auscultated over liver

Exam Action
10/06/20 7:05 AM MDT

Your avatar
 Auscultated over spleen

Exam Action
10/06/20 7:05 AM MDT

Your avatar
 Palpated right carotid pulse: Thrill, 3+

Exam Action
10/06/20 7:05 AM MDT

Your avatar
 Palpated left carotid pulse: No thrill, 2+

Exam Action
10/06/20 7:06 AM MDT

Your avatar
 Palpated PMI: Displaced laterally; brisk and tapping; less than 3 cm

Exam Action
10/06/20 7:06 AM MDT

Your avatar
 Palpated right brachial pulse: No thrill, 2+

Exam Action
10/06/20 7:07 AM MDT

Your avatar
 Palpated left brachial pulse: No thrill, 2+

Exam Action
10/06/20 7:07 AM MDT

Your avatar
 Palpated right radial pulse: No thrill, 2+

Exam Action
10/06/20 7:18 AM MDT

Your avatar
 Palpated left radial pulse: No thrill, 2+

Exam Action
10/06/20 7:19 AM MDT

Your avatar
 Palpated right femoral pulse: No thrill, 2+

Exam Action
10/06/20 7:19 AM MDT

Your avatar
 Palpated left femoral pulse: No thrill, 2+

Exam Action
10/06/20 7:19 AM MDT

Your avatar
 Palpated right popliteal pulse: No thrill, 1+

Exam Action
10/06/20 7:20 AM MDT

Your avatar
 Palpated left popliteal pulse: No thrill, 1+

Exam Action
10/06/20 7:20 AM MDT

Your avatar
 Palpated right tibial pulse: No thrill, 1+

Exam Action
10/06/20 7:22 AM MDT

Your avatar
 Palpated right tibial pulse: No thrill, 1+

Exam Action
10/06/20 7:23 AM MDT

Your avatar
 Palpated left tibial pulse: No thrill, 1+

Exam Action
10/06/20 7:23 AM MDT

Your avatar
 Palpated right dorsalis pedis pulse: No thrill, 1+

Exam Action
10/06/20 7:23 AM MDT

Your avatar
 Palpated left dorsalis pedis pulse: No thrill, 1+

Exam Action
10/06/20 7:23 AM MDT

Your avatar
 Palpated right upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension

Exam Action
10/06/20 7:25 AM MDT

Your avatar
 Palpated left upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension

Exam Action
10/06/20 7:26 AM MDT

Your avatar
 Palpated left lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension

Exam Action
10/06/20 7:26 AM MDT

Your avatar
 Palpated right lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension.

Exam Action
10/06/20 7:26 AM MDT

Your avatar
 Percussed right upper quadrant

Exam Action
10/06/20 7:27 AM MDT

Your avatar
 Percussed left upper quadrant

Exam Action
10/06/20 7:27 AM MDT

Your avatar
 Percussed right lower quadrant

Exam Action
10/06/20 7:27 AM MDT

Your avatar
 Percussed left lower quadrant

Exam Action
10/06/20 7:27 AM MDT

Your avatar
 Percussed spleen

Exam Action
10/06/20 7:27 AM MDT

Your avatar
 Percussed for liver span: 7 cm in the mid-clavicular line

Exam Action
10/06/20 7:28 AM MDT

Your avatar
 Performed EKG

Exam Action
10/06/20 7:28 AM MDT

Your avatar
Thank you Mr. Foster. I’m done with physical evaluation

Educate
10/06/20 7:30 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
Houston Foster how old are you ? (No matching questions found.)

Question
10/07/20 4:13 AM MDT

Your avatar
Mr.Foster how old are you ?

Question
10/07/20 4:13 AM MDT

Brian Foster
I’m 58 going on 30.
Your avatar
Early happy birthday

Empathize
10/07/20 4:14 AM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
Is it physical activity activates the pain ?

Question
10/07/20 4:53 AM MDT

Brian Foster
Well I used to ride my bike a lot but it got stolen a couple years ago. I guess I haven’t had much regular exercise since then. I want to get a new bike if the doctor says it is OK to exercise with this chest pain I’ve been having.
Your avatar
Sorry to hear that

Empathize
10/07/20 4:53 AM MDT

Brian Foster
Thanks. I appreciate that.
Your avatar
What aggravates your pain ?

Question
10/07/20 4:54 AM MDT

Brian Foster
Well, I think it’s when I’m doing something physical most of the time. The first time it happened, my chest started hurting after I was doing some yard work. The second time happened when the elevator broke at work so I had to take the stairs. My office is on the 5th floor.
Your avatar
Do you like red meat ?

Question
10/07/20 5:59 AM MDT

Brian Foster
Yes, yes I do.
Your avatar
Do you like vegetables and fruits ?

Educate
10/07/20 5:59 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
Do you like fruits and vegetables ? (No matching questions found.)

Question
10/07/20 5:59 AM MDT

Your avatar
If your diet include fruits and vegetables ? (No matching questions found.)

Question
10/07/20 6:00 AM MDT

Your avatar
You need to cut to read me like a beef pork and lamb because this meat is saturated with a bad cholesterol or fat. More than chicken and fish. Saturated and transfat can raise your blood cholesterol and make your heart disease worse.

Educate
10/07/20 6:05 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
You can replace the red meat by chicken or fish like a salmon which has a good cholesterol which which will help you to reduce your bad cholesterol and help you with your heart and cholesterol problems.

Educate
10/07/20 6:07 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
You need to start light exercising.

Educate
10/07/20 6:07 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
You need to include fresh vegetables and fruit in your diet.

Educate
10/07/20 6:08 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
You also need to continue taking your medications as prescribed.

Educate
10/07/20 6:08 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
You also need to wait yourself daily in the same clothes in the same time.

Educate
10/07/20 6:09 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
You need to do light exercise has three to four times a week.

Educate
10/07/20 6:09 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
Mister Foster you need to follow up with a primary care physician and a cardiologist. (No matching questions found.)

Question
10/07/20 6:10 AM MDT

Your avatar
Mister Foster you need to follow up with a primary care physician and a cardiologist.

Educate
10/07/20 6:10 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
You also need to eliminate you alcoholic beverages.

Educate
10/07/20 6:11 AM MDT

Brian Foster
Good to know. Thank you.
Your avatar
What is your height and weight ?

Question
10/07/20 6:13 AM MDT

Brian Foster
I’m five foot eleven.
Your avatar
What is your weight ?

Question
10/07/20 6:14 AM MDT

Brian Foster
As of this morning, a buck ninety-seven.
Your avatar
I am done with your exam Mr.Foster. Thank you for letting me to examine you. Have a good day. (No matching questions found.)

Question
10/09/20 7:43 AM MDT

Your avatar
I am done with your exam Mr.Foster. Thank you for letting me to examine you. Have a good day.

Educate
10/09/20 7:43 AM MDT

Brian Foster
EducateSpeech
Your avatar
Mr. Foster I just wanted to partially examine you again (No matching questions found.)

Question
10/12/20 1:39 AM MDT

Your avatar
Mr. Foster I just wanted to partially examine you again

Educate
10/12/20 1:40 AM MDT

Brian Foster
EducateSpeech
Your avatar
 Auscultated over liver

Exam Action
10/12/20 1:40 AM MDT

Your avatar
 Auscultated over spleen

Exam Action
10/12/20 1:41 AM MDT

Your avatar
 Auscultated over liver

Exam Action
10/12/20 1:41 AM MDT

Your avatar
 Percussed right upper quadrant

Exam Action
10/12/20 1:43 AM MDT

Your avatar
 Percussed left upper quadrant

Exam Action
10/12/20 1:43 AM MDT

Your avatar
 Percussed right lower quadrant

Exam Action
10/12/20 1:43 AM MDT

Your avatar
 Percussed left lower quadrant

Exam Action
10/12/20 1:43 AM MDT

Your avatar
Thank you Mr. Foster. I am done.

Educate
10/12/20 1:50 AM MDT

Brian Foster
EducateSpeech
Your avatar
 Percussed spleen

Exam Action
10/18/20 5:58 PM MDT

Your avatar
 Percussed spleen

Exam Action
10/18/20 5:58 PM MDT

Your avatar
 Inspected left leg

Exam Action
10/18/20 6:24 PM MDT

Your avatar
 Inspected right leg

Exam Action
10/18/20 6:24 PM MDT

Your avatar
 Inspected toenails on left foot

Exam Action
10/18/20 6:24 PM MDT

Your avatar
 Inspected left leg

Exam Action
10/18/20 6:24 PM MDT

Your avatar
 Inspected right leg

Exam Action
10/18/20 6:24 PM MDT

Your avatar
 Inspected toenails on right foot

Exam Action
10/18/20 6:25 PM MDT

Your avatar
 Inspected left leg

Exam Action
10/18/20 6:25 PM MDT

Your avatar
 Inspected right leg

Exam Action
10/18/20 6:25 PM MDT

Your avatar
 Inspected toenails on left foot

Exam Action
10/18/20 6:25 PM MDT

Your avatar
 Inspected right leg for edema: No edema

Exam Action
10/18/20 6:25 PM MDT

Your avatar
 Inspected left leg for edema: No edema

Exam Action
10/18/20 6:25 PM MDT

Your avatar
 Auscultated aortic area with the bell

Exam Action
10/18/20 6:26 PM MDT

Your avatar
 Auscultated pulmonic area with the bell

Exam Action
10/18/20 6:26 PM MDT

Your avatar
 Auscultated Erb’s point with the bell

Exam Action
10/18/20 6:26 PM MDT

Your avatar
 Auscultated tricuspid area with the bell

Exam Action
10/18/20 6:26 PM MDT

Your avatar
 Auscultated mitral area with the bell

Exam Action
10/18/20 6:26 PM MDT

Your avatar
 Auscultated aortic area with the bell

Exam Action
10/18/20 6:27 PM MDT

Your avatar
 Auscultated pulmonic area with the bell

Exam Action
10/18/20 6:27 PM MDT

Your avatar
 Auscultated Erb’s point with the bell

Exam Action
10/18/20 6:27 PM MDT

Your avatar
 Auscultated tricuspid area with the bell

Exam Action
10/18/20 6:27 PM MDT

Your avatar
 Auscultated mitral area with the bell

Exam Action
10/18/20 6:27 PM MDT

Your avatar
 Percussed right upper quadrant

Exam Action
10/18/20 6:28 PM MDT

Your avatar
 Percussed left upper quadrant

Exam Action
10/18/20 6:28 PM MDT

Your avatar
 Percussed right lower quadrant

Exam Action
10/18/20 6:28 PM MDT

Your avatar
 Percussed left lower quadrant

Exam Action
10/18/20 6:28 PM MDT

Your avatar
 Inspected left leg

Exam Action
10/18/20 6:31 PM MDT

Your avatar
 Inspected right leg

Exam Action
10/18/20 6:31 PM MDT

Your avatar
 Inspected toenails on left foot

Exam Action
10/18/20 6:31 PM MDT

Your avatar
 Inspected toenails on right foot

Exam Action
10/18/20 6:31 PM MDT

Your avatar
 Inspected toenails on left foot

Exam Action
10/18/20 6:32 PM MDT

Your avatar
 Inspected toenails on right foot

Exam Action
10/18/20 6:32 PM MDT

Your avatar
 Inspected left leg

Exam Action
10/18/20 6:32 PM MDT

Your avatar
 Inspected right leg

Exam Action
10/18/20 6:32 PM MDT

Your avatar
 Inspected right leg for edema: No edema

Exam Action
10/18/20 6:32 PM MDT

Your avatar
 Inspected left leg for edema: No edema

Exam Action
10/18/20 6:32 PM MDT

Your avatar
 Measured vitals

Exam Action
10/18/20 6:39 PM MDT

Your avatar
 Palpated right carotid pulse: Thrill, 3+

Exam Action
10/18/20 6:39 PM MDT

Your avatar
 Palpated left carotid pulse: No thrill, 2+

Exam Action
10/18/20 6:39 PM MDT

Your avatar
 Palpated right carotid pulse: Thrill, 3+

Exam Action
10/18/20 6:40 PM MDT

Your avatar
 Palpated right carotid pulse: Thrill, 3+

Exam Action
10/18/20 6:41 PM MDT

Your avatar
 Palpated left carotid pulse: No thrill, 2+

Exam Action
10/18/20 6:41 PM MDT

Your avatar
 Palpated left carotid pulse: No thrill, 2+

Exam Action
10/18/20 6:41 PM MDT

Your avatar
 Auscultated aortic area with the bell

Exam Action
10/18/20 6:42 PM MDT

Your avatar
 Auscultated pulmonic area with the bell

Exam Action
10/18/20 6:42 PM MDT

Your avatar
 Auscultated Erb’s point with the bell

Exam Action
10/18/20 6:42 PM MDT

Your avatar
 Auscultated tricuspid area with the bell

Exam Action
10/18/20 6:42 PM MDT

Your avatar
 Auscultated mitral area with the bell

Exam Action
10/18/20 6:42 PM MDT

Your avatar
 Auscultated mitral area with the diaphragm

Exam Action
10/18/20 6:42 PM MDT

Your avatar
 Auscultated mitral area with the bell

Exam Action
10/18/20 6:42 PM MDT

Your avatar
 Auscultated tricuspid area with the bell

Exam Action
10/18/20 6:42 PM MDT

Your avatar
 Auscultated Erb’s point with the bell

Exam Action
10/18/20 6:42 PM MDT

Your avatar
 Auscultated pulmonic area with the bell

Exam Action
10/18/20 6:42 PM MDT

Your avatar
 Auscultated aortic area with the bell

Exam Action
10/18/20 6:42 PM MDT

Your avatar
 Auscultated pulmonic area with the bell

Exam Action
10/18/20 6:42 PM MDT

Your avatar
 Auscultated Erb’s point with the bell

Exam Action
10/18/20 6:42 PM MDT

Your avatar
 Auscultated tricuspid area with the bell

Exam Action
10/18/20 6:43 PM MDT

Your avatar
 Auscultated tricuspid area with the diaphragm

Exam Action
10/18/20 6:43 PM MDT

Your avatar
 Auscultated mitral area with the diaphragm

Exam Action
10/18/20 6:43 PM MDT

Your avatar
 Auscultated mitral area with the bell

Exam Action
10/18/20 6:43 PM MDT

Your avatar
 Auscultated tricuspid area with the bell

Exam Action
10/18/20 6:43 PM MDT

Your avatar
 Auscultated Erb’s point with the bell

Exam Action
10/18/20 6:43 PM MDT

Your avatar
 Auscultated pulmonic area with the bell

Exam Action
10/18/20 6:43 PM MDT

Your avatar
 Auscultated aortic area with the bell

Exam Action
10/18/20 6:43 PM MDT

Your avatar
 Measured vitals

Exam Action
10/18/20 6:44 PM MDT

Your avatar
 Inspected right hand: no visible abnormal findings

Exam Action
10/18/20 6:44 PM MDT

Your avatar
 Inspected left hand: no visible abnormal findings

Exam Action
10/18/20 6:44 PM MDT

Your avatar
 Inspected left leg

Exam Action
10/18/20 6:44 PM MDT

Your avatar
 Inspected right leg

Exam Action
10/18/20 6:44 PM MDT

Your avatar
 Inspected toenails on left foot

Exam Action
10/18/20 6:44 PM MDT

Your avatar
 Inspected toenails on right foot

Exam Action
10/18/20 6:44 PM MDT

Your avatar
 Inspected right hand: no visible abnormal findings

Exam Action
10/18/20 6:45 PM MDT

Your avatar
 Inspected left hand: no visible abnormal findings

Exam Action
10/18/20 6:45 PM MDT

Your avatar
 Inspected fingernails of left hand

Exam Action
10/18/20 6:45 PM MDT

Your avatar
 Inspected fingernails of right hand

Exam Action
10/18/20 6:45 PM MDT

Your avatar
 Inspected fingernails of left hand

Exam Action
10/18/20 6:46 PM MDT

Your avatar
 Inspected fingernails of right hand

Exam Action
10/18/20 6:46 PM MDT

Your avatar
 Inspected right hand: no visible abnormal findings

Exam Action
10/18/20 7:19 PM MDT

Your avatar
 Inspected left hand: no visible abnormal findings

Exam Action
10/18/20 7:19 PM MDT

Your avatar
 Inspected left leg

Exam Action
10/18/20 7:20 PM MDT

Your avatar
 Inspected right leg

Exam Action
10/18/20 7:20 PM MDT

Your avatar
Are you working ?

Question
10/18/20 9:42 PM MDT

Brian Foster
I work at a civil engineering firm here in town.
Your avatar
Do your sit a lot at work ? (Clarified to Do you sit down for long periods of time at work?.)

Question
10/18/20 9:43 PM MDT

Brian Foster
Well, yes, that’s the job. Unless I’m on site. [AUDIO COMING SOON] (Clarified to if I spend a lot of time sitting at work.)
Your avatar
What is the hours of working ?

Question
10/18/20 9:46 PM MDT

Brian Foster
I’m an engineer.
Your avatar
What is the working hours ?

Question
10/18/20 9:46 PM MDT

Brian Foster
My work life is pretty stable and generally low stress, I’d say.
Your avatar
It’s really good

Empathize
10/18/20 9:46 PM MDT

Brian Foster
EmpathizeSpeech
Your avatar
Do you like your job ?

Question
10/18/20 9:47 PM MDT

Brian Foster
Yeah, I like it. I’ve been there sixteen years.
Your avatar
It’s awesome

Empathize
10/18/20 9:47 PM MDT

Brian Foster
EmpathizeSpeech
Your avatar
Do you have a friends ?

Question
10/18/20 9:47 PM MDT

Brian Foster
Yep.
Your avatar
What type of social support do you have ? (No matching questions found.)

Question
10/18/20 9:48 PM MDT

Your avatar
Where your socialize ?

Question
10/18/20 9:48 PM MDT

Brian Foster
My social life is mostly my family now. My wife and I are together all the time, and my son and his family lives in town. My daughter is in college so she’s home at least once a month. We try to have big family dinners when she’s home. I go fishing with my friend Smitty and his brother every once in a while.
Your avatar
How often do you go to fishing ? (Clarified to How often do you go to church?.)

Question
10/18/20 9:51 PM MDT

Brian Foster
I don’t usually go unless it’s on a holiday when my mother is in town. (Clarified to how often I go to church.)
Your avatar
How often do mother comes in town ?

Question
10/18/20 9:51 PM MDT

Brian Foster
I think I pee a normal amount. Every couple of hours or so.

Subjective Data Collection: 30 of 30 (100.0%)

Hover To Reveal…

Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

  • Found:

     Indicates an item that you found.

  • Available:

     Indicates an item that is available to be found.

Category

Scored Items

Experts selected these topics as essential components of a strong, thorough interview with this patient.

Patient Data

Not Scored

A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.

Chief Complaint


  • Finding:

    Established chief complaint


  • Finding:

    Reports chest pain

    (Found)

    Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.

    Example Question:

    Do you have chest pain?

History of Present Illness


  • Finding:

    Asked about onset of pain


  • Finding:

    Reports chest pain started appearing in the past month

    (Found)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    When did your chest pain start?

  • Finding:

    Asked about location of pain


  • Finding:

    Reports pain is in center of the chest

    (Found)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    Where is the pain?

  • Finding:

    Reports pain does not radiate

    (Found)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    Does the pain radiate?

  • Finding:

    Denies arm pain

    (Found)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    Are you experiencing arm pain?

  • Finding:

    Denies shoulder pain

    (Found)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    Are you experiencing shoulder pain?

  • Finding:

    Denies back pain

    (Found)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    Are you experiencing back pain?

  • Finding:

    Denies neck pain

    (Available)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    Are you experiencing neck pain?

  • Finding:

    Asked about duration of pain episodes


  • Finding:

    Reports each pain episode lasted “several” minutes

    (Found)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    How long does your chest pain last?

  • Finding:

    Asked about frequency of pain


  • Finding:

    Reports 3 pain episodes in past month

    (Found)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    How many times in the last month have you had chest pain?

  • Finding:

    Reports that pain episodes did not seem related

    (Found)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    Did the episodes seem associated?

  • Finding:

    Asked about severity of pain


  • Finding:

    Reports current pain is 0 out of 10

    (Found)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    How would you rate your pain on a scale of zero to ten?

  • Finding:

    Reports pain severity at its worst is 5 out of 10

    (Found)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    How would you rate your pain on a scale of zero to ten?

  • Finding:

    Asked about characteristics of pain


  • Finding:

    Describes pain as tight and uncomfortable

    (Found)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    Can you describe your pain?

  • Finding:

    Denies crushing pain

    (Available)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    Is the pain crushing?

  • Finding:

    Denies gnawing pain

    (Available)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    Is the pain gnawing?

  • Finding:

    Denies burning pain

    (Available)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    Is the pain burning?

  • Finding:

    Asked about aggravating factors


  • Finding:

    Reports pain is aggravated by activity

    (Found)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    What makes the pain worse?

  • Finding:

    Reports pain occurred with yard work and taking stairs

    (Found)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    What activity triggered the pain?

  • Finding:

    Reports pain does not worsen with eating

    (Found)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    Is the pain worse when you eat?

  • Finding:

    Reports pain does not worsen after spicy foods

    (Available)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    Is the pain worse after you eat spicy food?

  • Finding:

    Reports pain does not worsen after high-fat foods

    (Found)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    Is the pain worse after you eat high-fat foods?

  • Finding:

    Asked about relieving factors


  • Finding:

    Reports pain relief with brief period of rest

    (Found)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    What relieves your pain?

  • Finding:

    Denies taking medication to treat chest pain

    (Found)

    Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

    Example Question:

    Did you take anything for the chest pain?

Past Medical History


  • Finding:

    Confirmed allergies


  • Finding:

    Confirms allergies

    (Found)

    Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

    Example Question:

    Do you have new allergies?

  • Finding:

    Asked about related medical conditions


  • Finding:

    Denies angina diagnosis

    (Found)

    Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

    Example Question:

    Do you have a history of angina?

  • Finding:

    Reports high blood pressure

    (Found)

    Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

    Example Question:

    Do you have high blood pressure?

  • Finding:

    Reports high cholesterol

    (Found)

    Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

    Example Question:

    Do you have high cholesterol?

  • Finding:

    Denies coronary artery disease

    (Available)

    Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

    Example Question:

    Do you have coronary artery disease?

  • Finding:

    Denies diabetes

    (Found)

    Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

    Example Question:

    Do you have diabetes?

  • Finding:

    Denies previous treatment for chest pain

    (Found)

    Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

    Example Question:

    Have you had previous treatment for chest pain?

  • Finding:

    Asked about blood pressure monitoring


  • Finding:

    Does not frequently monitor BP at home

    (Found)

    Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

    Example Question:

    How often do you measure your blood pressure?

  • Finding:

    Reports infrequent BP checks

    (Found)

    Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

    Example Question:

    When do you measure your blood pressure?

  • Finding:

    Denies knowledge of typical BP reading

    (Found)

    Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

    Example Question:

    What is your typical blood pressure reading?

  • Finding:

    Asked about past cardiac tests


  • Finding:

    Reports recent EKG test

    (Found)

    Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

    Example Question:

    Have you recently had an EKG?

  • Finding:

    Reports annual stress test

    (Available)

    Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

    Example Question:

    Have you recently had a stress test?

  • Finding:

    Followed up on results of cardiac tests


  • Finding:

    Reports belief that EKG was normal

    (Found)

    Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

    Example Question:

    What were the results of your last EKG?

  • Finding:

    Reports belief that stress test was normal

    (Available)

    Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

    Example Question:

    What were the results of your last stress test?

Home Medications


  • Finding:

    Asked about home medications


  • Finding:

    Reports taking high blood pressure medication

    (Found)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    Do you take medication for high blood pressure?

  • Finding:

    Reports taking high cholesterol medication

    (Found)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    Do you take medication for high cholesterol?

  • Finding:

    Reports occasional ibuprofen use

    (Found)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    Do you take over the counter medications?

  • Finding:

    Reports taking fish oil

    (Found)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    Do you take any supplements?

  • Finding:

    Denies aspirin regimen

    (Found)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    Do you take aspirin?

  • Finding:

    Followed up on high blood pressure medication


  • Finding:

    Reports taking lisinopril

    (Available)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    What medication do you take for high blood pressure?

  • Finding:

    Reports lisinopril dose is 20 mg

    (Available)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    What dose of medication do you take for high blood pressure?

  • Finding:

    Reports taking lisinopril once daily

    (Available)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    How frequently do you take medication for high blood pressure?

  • Finding:

    Followed up on high cholesterol medication


  • Finding:

    Reports taking atorvastatin

    (Found)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    What medication do you take for high cholesterol?

  • Finding:

    Reports atorvastatin dose is 20 mg

    (Found)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    What dose of medication do you take for high cholesterol?

  • Finding:

    Reports taking atorvastatin once daily

    (Found)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    How frequently do you take medication for high cholesterol?

  • Finding:

    Reports taking atorvastatin at bedtime

    (Available)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    What time of day do you take your high cholesterol medication?

  • Finding:

    Reports having taken atorvastatin for one year

    (Available)

    Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

    Example Question:

    How long have you taken cholesterol medication?

Social Determinants of Health


  • Finding:

    Asked about access to healthcare


  • Finding:

    Reports a primary care provider

    (Found)

    Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

    Example Question:

    Do you have a primary care provider?

  • Finding:

    Reports last visit 3 months ago

    (Found)

    Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

    Example Question:

    When was your last visit to a healthcare provider?

  • Finding:

    Reports usually sees healthcare provider every 6 months

    (Available)

    Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

    Example Question:

    How often do you see a healthcare provider?

  • Finding:

    Denies transportation is a barrier to healthcare

    (Available)

    Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

    Example Question:

    Do you have difficulty accessing healthcare because of transportation?

  • Finding:

    Denies finances are a barrier to healthcare

    (Available)

    Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

    Example Question:

    Do you have trouble affording healthcare?

Social History


  • Finding:

    Asked about stress


  • Finding:

    Reports generally low stress lifestyle

    (Found)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    What is your stress level?

  • Finding:

    Asked about exercise


  • Finding:

    Denies regular exercise routine

    (Found)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    What kind of exercise do you get?

  • Finding:

    Reports last regular exercising was 2 years ago

    (Found)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    When did you last exercise regularly?

  • Finding:

    Asked about typical diet


  • Finding:

    Reports typical breakfast is granola bar and instant breakfast shake

    (Found)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    What is a typical breakfast for you?

  • Finding:

    Reports typical lunch is turkey sub

    (Found)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    What is a typical lunch for you?

  • Finding:

    Reports typical dinner is grilled meat and vegetables

    (Found)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    What is a typical dinner for you?

  • Finding:

    Denies moderation of salt intake

    (Available)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    Do you moderate your salt intake?

  • Finding:

    Asked about fluid intake


  • Finding:

    Reports drinking 4 glasses of water daily

    (Found)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    Do you drink water every day?

  • Finding:

    Reports drinking 2 cups of coffee daily

    (Available)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    How much coffee do you drink per day?

  • Finding:

    Denies soda drinking

    (Available)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    How much soda do you drink per day?

  • Finding:

    Asked about substance use


  • Finding:

    Denies current illicit drug use

    (Found)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    Do you use illicit drugs?

  • Finding:

    Denies tobacco use

    (Found)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    Do you use tobacco?

  • Finding:

    Reports moderate alcohol consumption

    (Found)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    Do you consume alcohol?

  • Finding:

    Followed up on alcohol consumption


  • Finding:

    Reports drinking 2-3 alcoholic drinks per week

    (Found)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    Do you drink alcohol?

  • Finding:

    Reports 2-3 drinks in one sitting

    (Available)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    How many alcoholic drinks do you have in one sitting?

  • Finding:

    Reports drinking only on weekends

    (Found)

    Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

    Example Question:

    When do you drink alcohol?

Review of Systems


  • Finding:

    Asked about constitutional health


  • Finding:

    Denies fever

    (Found)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have a fever?

  • Finding:

    Denies chills

    (Found)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have chills?

  • Finding:

    Denies fatigue

    (Found)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you feel tired?

  • Finding:

    Denies night sweats

    (Found)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have night sweats?

  • Finding:

    Denies weight loss

    (Found)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Have you experienced recent weight loss?

  • Finding:

    Denies dizziness or lightheadedness

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have dizziness?

  • Finding:

    Denies palpitations

    (Found)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have palpitations?

  • Finding:

    Asked review of systems for cardiovascular


  • Finding:

    Denies history of angina

    (Found)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have a history of angina?

  • Finding:

    Denies edema

    (Found)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have any swelling?

  • Finding:

    Denies circulation problems

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have any problems with circulation?

  • Finding:

    Denies blood clots

    (Found)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Have you ever had a blood clot?

  • Finding:

    Denies history of rheumatic fever

    (Found)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have a history of rheumatic fever?

  • Finding:

    Denies history of heart murmur

    (Found)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have a history of heart murmur?

  • Finding:

    Denies easy bleeding

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Have you noticed any unusual bleeding?

  • Finding:

    Denies easy bruising

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Have you noticed any unusual bruising?

  • Finding:

    Denies blue skin

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Has your skin ever turned blue?

  • Finding:

    Asked about review of systems for respiratory


  • Finding:

    Denies cough

    (Found)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have a cough?

  • Finding:

    Denies difficulty breathing

    (Found)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Have you had difficulty breathing?

  • Finding:

    Denies shortness of breath at rest

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have difficulty breathing when lying down?

  • Finding:

    Asked about review of systems for HEENT


  • Finding:

    Denies change in sense of taste

    (Found)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Have you experienced a change in taste?

  • Finding:

    Denies sore throat

    (Found)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have a sore throat?

  • Finding:

    Denies difficulty swallowing

    (Found)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have dysphagia?

  • Finding:

    Asked about review of systems for gastrointestinal


  • Finding:

    Denies nausea

    (Found)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have nausea?

  • Finding:

    Denies vomiting

    (Found)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Have you vomited recently?

  • Finding:

    Denies diarrhea

    (Found)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have diarrhea?

  • Finding:

    Denies constipation

    (Found)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have constipation?

  • Finding:

    Denies gassiness

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Have you been gassy?

  • Finding:

    Denies bloating

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have bloating?

  • Finding:

    Denies heartburn or GERD

    (Available)

    Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

    Example Question:

    Do you have heartburn or GERD?

Family Medical History


  • Finding:

    Asked about relevant family history


  • Finding:

    Reports family history of heart attack

    (Found)

    Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.

    Example Question:

    Has anyone in your family had a heart attack?

  • Finding:

    Denies family history of stroke

    (Found)

    Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it.

    Example Question:

    Do you have a family history of stroke?

  • Finding:

    Denies family history of pulmonary embolism

Objective Data Collection: 31 of 33 (93.94%)

  •  Correct
  •  Partially correct
  •  Incorrect
  •  Missed
 Inspected face
1 of 1 point
Appearance (1/1 point)
  •  No visible abnormal findings
  •  Rash or lesion
  •  Cyanosis
  •  Pallor
  •  Redness or flushing
  •  Evidence of trauma (scar, laceration, or bruising)
 Inspected for jugular venous distension
1 of 1 point
Height Of Venous Pressure (1/1 point)
  •  4 cm or less above the sternal angle
  •  More than 4 cm above the sternal angle
 Inspected chest
1 of 1 point
Symmetry (1/2 point)
  •  Symmetric
  •  Asymmetric
Appearance (1/2 point)
  •  No visible abnormal findings
  •  Rash or lesion
  •  AP diameter abnormal
  •  Intercostal retraction while breathing
  •  Excessive use of accessory muscles while breathing
  •  Pectus excavatum
  •  Skin growths (freckles or moles)
  •  Evidence of skin trauma (scar, laceration, or bruising)
 Inspected abdomen
1 of 1 point
Symmetry (1/3 point)
  •  Symmetric
  •  Asymmetric
Contour (1/3 point)
  •  Flat
  •  Rounded
  •  Protuberant
  •  Hollowed
Appearance (1/3 point)
  •  No visible abnormal findings
  •  Rash
  •  Striae
  •  Bulging around umbilicus
  •  Distension
  •  Visible masses (warts, cysts, or tumors)
  •  Freckles, birthmark, or discoloration
  •  Excessive hair growth
  •  Visible scars
  •  Laceration, lesion or wound
  •  Bruising
 Inspected hands and fingernails
0.5 of 1 point
Right: Appearance (1/4 point)
  •  No visible abnormal findings
  •  Redness
  •  Moles or skin tags
  •  Masses (warts, cysts, or tumors)
  •  Freckles, birthmark, or other discoloration
  •  Excessive dry or flaking skin
  •  Purpura
  •  Scarring
  •  Laceration, lesion, or wound
  •  Bruising
  •  Rash
Right: Nail Changes (No point)
  •  No visible abnormal findings
  •  Pallor
  •  Cyanosis
  •  Splinter hemorrhages
  •  Clubbing
Left: Appearance (1/4 point)
  •  No visible abnormal findings
  •  Redness
  •  Moles or skin tags
  •  Masses (warts, cysts, or tumors)
  •  Freckles, birthmark, or other discoloration
  •  Excessive dry or flaking skin
  •  Purpura
  •  Scarring
  •  Laceration, lesion, or wound
  •  Bruising
  •  Rash
Left: Nail Changes (No point)
  •  No visible abnormal findings
  •  Pallor
  •  Cyanosis
  •  Splinter hemorrhages
  •  Clubbing
 Inspected lower extremities and toenails
0.5 of 1 point
Right: Appearance (1/4 point)
  •  No visible abnormal findings
  •  Visible distortion or swelling
  •  Brownish pigmentation
  •  Skin thickening
  •  Ulceration
  •  Varicose veins
Right: Nail Changes (No point)
  •  No visible abnormal findings
  •  Pallor
  •  Cyanosis
  •  Splinter hemorrhages
  •  Clubbing
Left: Appearance (1/4 point)
  •  No visible abnormal findings
  •  Visible distortion or swelling
  •  Brownish pigmentation
  •  Skin thickening
  •  Ulceration
  •  Varicose veins
Left: Nail Changes (No point)
  •  No visible abnormal findings
  •  Pallor
  •  Cyanosis
  •  Splinter hemorrhages
  •  Clubbing
 Inspect lower extremities for edema
1 of 1 point
Right: Edema (1/4 point)
  •  No edema
  •  Pitting
  •  Non-pitting
Right: Severity Of Edema (1/4 point)
  •  No edema
  •  1+ Slight pitting
  •  2+ Deeper pit, disappears in 10 to 15 seconds
  •  3+ Noticeably deep pit that lasts more than a minute
  •  4+ Very deep pit that lasts 2 to 5 minutes
Left: Edema (1/4 point)
  •  No edema
  •  Pitting
  •  Non-pitting
Left: Severity Of Edema (1/4 point)
  •  No edema
  •  1+ Slight pitting
  •  2+ Deeper pit, disappears in 10 to 15 seconds
  •  3+ Noticeably deep pit that lasts more than a minute
  •  4+ Very deep pit that lasts 2 to 5 minutes
 Tested capillary refill time
1 of 1 point
Fingers (1/2 point)
  •  Less than 3 seconds
  •  Greater than 3 seconds
Toes (1/2 point)
  •  Less than 3 seconds
  •  Greater than 3 seconds
 Auscultated carotid arteries
0.5 of 1 point
Right (1/2 point)
  •  No bruit
  •  Bruit
Left (No point)
  •  No bruit
  •  Bruit
 Auscultated heart sounds
0.5 of 1 point
Heart Sounds (No point)
  •  S1 and S2 audible
  •  S1, S2, and S3 audible
  •  S1, S2, and S4 audible
  •  S1, S2, S3, and S4 audible
Extra Heart Sounds (1/2 point)
  •  No extra sounds
  •  Gallops
  •  Murmur
  •  Friction rub
  •  Valve clicks
 Auscultated breath sounds
1 of 1 point
Breath Sounds (1/3 point)
  •  Present in all areas
  •  Diminished in some areas
  •  Absent in some areas
Adventitious Sounds (1/3 point)
  •  No adventitious sounds
  •  Wheezing
  •  Fine crackles
  •  Stridor
  •  Rhonchi
  •  Course crackles
Location (1/3 point)
  •  All areas clear
  •  Adventitious sounds in anterior right upper lobe
  •  Adventitious sounds in anterior right middle lobe
  •  Adventitious sounds in anterior right lower lobe
  •  Adventitious sounds in anterior left upper lobe
  •  Adventitious sounds in anterior left lower lobe
  •  Adventitious sounds in posterior right upper lobe
  •  Adventitious sounds in posterior right lower lobe
  •  Adventitious sounds in posterior left upper lobe
  •  Adventitious sounds in posterior left lower lobe
 Auscultated abdominal aorta
1 of 1 point 
Sounds (1/1 point)
  •  No bruit
  •  Bruit
 Auscultated abdominal and lower extremity arteries
1 of 1 point
Right: Renal (1/6 point)
  •  No bruit
  •  Bruit
Left: Renal (1/6 point)
  •  No bruit
  •  Bruit
Right: Iliac (1/6 point)
  •  No bruit
  •  Bruit
Left: Iliac (1/6 point)
  •  No bruit
  •  Bruit
Right: Femoral (1/6 point)
  •  No bruit
  •  Bruit
Left: Femoral (1/6 point)
  •  No bruit
  •  Bruit
 Auscultated bowel sounds
1 of 1 point
Bowel Sounds (1/2 point)
  •  Absent
  •  Hypoactive
  •  Normoactive
  •  Hyperactive
Location Of Non Normoactive Bowel Sounds (1/2 point)
  •  All quadrants normoactive
  •  Right upper quadrant
  •  Right lower quadrant
  •  Left upper quadrant
  •  Left lower quadrant
 Palpated carotid arteries
1 of 1 point
Right: Vibration (1/4 point)
  •  No thrill
  •  Thrill
Right: Amplitude (1/4 point)
  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse
Left: Vibration (1/4 point)
  •  No thrill
  •  Thrill
Left: Amplitude (1/4 point)
  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse
 Palpated PMI
1 of 1 point
Location (1/3 point)
  •  Present at midclavicular line and 5th intercostal space
  •  Displaced laterally
Diameter (1/3 point)
  •  Less than 3 cm
  •  Greater than 3 cm
Amplitude (1/3 point)
  •  Brisk and tapping
  •  Increased amplitude (hyperkinetic)
 Palpated brachial arteries
1 of 1 point
Right: Vibration (1/4 point)
  •  No thrill
  •  Thrill
Right: Amplitude (1/4 point)
  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse
Left: Vibration (1/4 point)
  •  No thrill
  •  Thrill
Left: Amplitude (1/4 point)
  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse
 Palpated radial arteries
1 of 1 point
Right: Vibration (1/4 point)
  •  No thrill
  •  Thrill
Right: Amplitude (1/4 point) 
  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse
Left: Vibration (1/4 point)
  •  No thrill
  •  Thrill
Left: Amplitude (1/4 point)
  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse
 Palpated femoral arteries
1 of 1 point
Right: Vibration (1/4 point)
  •  No thrill
  •  Thrill
Right: Amplitude (1/4 point)
  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse
Left: Vibration (1/4 point)
  •  No thrill
  •  Thrill
Left: Amplitude (1/4 point)
  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse
 Palpated popliteal arteries
1 of 1 point
Right: Vibration (1/4 point)
  •  No thrill
  •  Thrill
Right: Amplitude (1/4 point)
  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse
Left: Vibration (1/4 point)
  •  No thrill
  •  Thrill
Left: Amplitude (1/4 point)
  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse
 Palpated tibial arteries
1 of 1 point
Right: Vibration (1/4 point)
  •  No thrill
  •  Thrill
Right: Amplitude (1/4 point)
  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse
Left: Vibration (1/4 point)
  •  No thrill
  •  Thrill
Left: Amplitude (1/4 point)
  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse
 Palpated dorsalis pedis arteries
1 of 1 point
Right: Vibration (1/4 point)
  •  No thrill
  •  Thrill
Right: Amplitude (1/4 point)
  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse
Left: Vibration (1/4 point)
  •  No thrill
  •  Thrill
Left: Amplitude (1/4 point)
  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse
 Palpated abdomen – light
1 of 1 point
Tenderness (1/3 point)
  •  None reported
  •  Tenderness reported
Location Of Tenderness (1/3 point)
  •  No quadrants tender
  •  Right upper quadrant
  •  Right lower quadrant
  •  Left upper quadrant
  •  Left lower quadrant
Observations (1/3 point)
  •  No additional observations
  •  Masses
  •  Guarding
  •  Distension
  •  Muscle resistance
  •  Rigidity
 Palpated abdomen – deep
1 of 1 point
Presence Of Unexpected Mass (1/2 point)
  •  No palpable mass
  •  Palpable mass
Location Of Mass (1/2 point)
  •  No palpable mass
  •  Right upper quadrant
  •  Right lower quadrant
  •  Left upper quadrant
  •  Left lower quadrant
  •  Around umbilicus
 Palpated liver
1 of 1 point
Detection (1/1 point)
  •  Not palpable
  •  Palpable
 Palpated spleen
1 of 1 point
Detection (1/1 point)
  •  Not palpable
  •  Palpable
 Palpated kidneys
1 of 1 point
Right (1/2 point)
  •  Not palpable
  •  Palpable
Left (1/2 point)
  •  Not palpable
  •  Palpable
 Tested skin turgor
1 of 1 point
Observations (1/1 point)
  •  No tenting
  •  Tenting
 Auscultated organs
1 of 1 point
Liver (1/2 point)
  •  No friction rub
  •  Audible friction rub
Spleen (1/2 point) 
  •  No friction rub
  •  Audible friction rub
 Percussed abdomen
1 of 1 point
Observations (1/1 point)
  •  All areas generally tympanic
  •  Some areas dull, some tympanic
  •  Some areas resonant
 Percussed spleen
1 of 1 point
Spleen (1/1 point)
  •  Tympany
  •  Dullness
 Percussed liver
1 of 1 point
Liver Span (1/1 point)
  •  Smaller than 6 cm
  •  Between 6 and 12 cm
  •  Greater than 12 cm
 Performed EKG
1 of 1 point
Sinus Rhythm (1/2 point)
  •  Regular
  •  Irregular
St Changes (1/2 point)
  •  No ST elevation
  •  ST elevation present

Education & Empathy : 6 of 6 (100.0%)

During the patient interview, there are a number of opportunities to provide patient education and empathy. The opportunities listed below are those identified by nursing experts to be of particular importance to this patient. A Model Statement is provided as an example of an appropriate response to each opportunity.

  • Opportunities marked as Not Encountered are opportunities that were not elicited in the interview
  • Opportunities marked as Not Followed Up are missed opportunities that were present in the interview, but where no statements were made
  • Opportunities marked as Followed Up were followed up by students, and include the dialogue between student and patient
 1 Symptoms
Followed Up

 Description: Mr. Foster describes the symptoms that have been bothering him.

This is your avatar.

What brought you here today ?

Question
01:18 PM MDT

Brian Foster

I have been having some troubling chest pain in my chest now and then for the past month.

This is your avatar.

Oh I’m sorry to hear that, it should be very uncomfortable to have that pain for a whole month.

Empathize
01:22 PM MDT

Brian Foster

Thanks. I appreciate that.

This is your avatar.

What is the onset of your pain ?

Question
01:23 PM MDT

Brian Foster

I first noticed it earlier this month. I thought it might just be heartburn and it passed after about a couple of minutes.

This is your avatar.

What is the exact location of the pain ?

Question
01:24 PM MDT

Brian Foster

When the pain happens, I feel it mostly in the middle of my chest, over my heart.

This is your avatar.

When did you chest pain start ?

Question
01:25 PM MDT

Brian Foster

I first noticed it earlier this month. I thought it might just be heartburn and it passed after a couple of minutes.

This is your avatar.

What is the exact location of the pain ?

Question
01:25 PM MDT

Brian Foster

When the pain happens, I feel it mostly in the middle of my chest, over my heart.

This is your avatar.

Sorry to hear that

Empathize
01:26 PM MDT

Brian Foster

Thanks. I appreciate that.

This is your avatar.

Easter pain radiates anywhere ? (Clarified to: Is your pain radiating?)

Question
01:26 PM MDT

Brian Foster

The pain doesn’t radiate anywhere. It’s mostly just right in the middle of my chest. (Clarified to: if the pain is radiating)

This is your avatar.

If your arm hurts (Clarified to: Do you have pain in your arm?)

Question
01:26 PM MDT

Brian Foster

No, when I am having the chest pain, it’s mostly just in middle of my chest. (Clarified to: if I have pain in my arm)

This is your avatar.

Do you have a pain in your shoulder ?

Question
01:27 PM MDT

Brian Foster

No, the pain hasn’t been in my shoulder.

This is your avatar.

Do you have a back pain ?

Question
01:27 PM MDT

Brian Foster

I haven’t had back pain, no.

This is your avatar.

Can you describe the duration of the pain ? (Clarified to: Can you tell me what the pain is like?)

Question
01:28 PM MDT

Brian Foster

Well, it mostly feels tight and uncomfortable right in the middle of my chest. (Clarified to: if I can tell you what the pain is like)

This is your avatar.

How often pain occurs ? (Clarified to: How often do you have pain?)

Question
01:29 PM MDT

Brian Foster

Well, it has happened three times the past month. It usually goes away after about a couple of minutes. (Clarified to: how often I have pain)

This is your avatar.

Can you describe your pain from 0 to 10 scale ?

Question
01:29 PM MDT

Brian Foster

I’d say maybe a . . . 5? It’s just really uncomfortable . . . like there’s nothing I can do about it. Right now it’s like a zero though.

This is your avatar.

Sorry to hear that

Empathize
01:30 PM MDT

Brian Foster

Thanks. I appreciate that.

This is your avatar.

Where else do you have a pain ?

Question
02:36 PM MDT

Brian Foster

No, when I am having the chest pain, it’s mostly just in middle of my chest.

This is your avatar.

Do you have a pain somewhere else in your body ?

Question
02:37 PM MDT

Brian Foster

No, when I am having the chest pain, it’s mostly just in middle of my chest.

This is your avatar.

What is the aggravating factors ? (Clarified to: Are there any aggravating factors?)

Question
02:37 PM MDT

Brian Foster

Well, the pain seems to start when I’m doing something physical . . . the first time it happened while I was doing yard work, and the second time . . . I had to take the stairs at work because the elevator broke. Both times it got better if I took a break or sat down to rest. (Clarified to: if there are aggravating factors)

This is your avatar.

What activity triggers pain ?

Question
02:39 PM MDT

Brian Foster

If I’m up and moving around I definitely notice it more and it makes me feel like I should sit down and take a deep breath or something.

This is your avatar.

He’s a pain worse when you eat ?

Question
02:40 PM MDT

Brian Foster

I don’t think eating has anything to do with it. One episode did happen when my wife and I were out for dinner, but it seemed to happen before we even settled. The episodes don’t seem all that related, to be honest.

This is your avatar.

It can be a lot of triggers in your diet which would aggravate and trigger your pain Mr.Foster.

Educate
02:43 PM MDT

Brian Foster

Good to know. Thank you.

This is your avatar.

Do you have stress ?

Question
06:36 AM MDT

Brian Foster

Not usually, but I’m feeling pretty anxious not knowing what’s going on with my chest.

This is your avatar.

I’m sorry to hear that

Empathize
06:36 AM MDT

Brian Foster

Thanks. I appreciate that.

This is your avatar.

What aggravates your pain ?

Question
04:54 AM MDT

Brian Foster

Well, I think it’s when I’m doing something physical most of the time. The first time it happened, my chest started hurting after I was doing some yard work. The second time happened when the elevator broke at work so I had to take the stairs. My office is on the 5th floor.

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Do you like red meat ?

Question
05:59 AM MDT

Brian Foster

Yes, yes I do.

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Do you like vegetables and fruits ?

Educate
05:59 AM MDT

Brian Foster

Good to know. Thank you.

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You need to cut to read me like a beef pork and lamb because this meat is saturated with a bad cholesterol or fat. More than chicken and fish. Saturated and transfat can raise your blood cholesterol and make your heart disease worse.

Educate
06:05 AM MDT

Brian Foster

Good to know. Thank you.

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You can replace the red meat by chicken or fish like a salmon which has a good cholesterol which which will help you to reduce your bad cholesterol and help you with your heart and cholesterol problems.

Educate
06:07 AM MDT

Brian Foster

Good to know. Thank you.

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You need to start light exercising.

Educate
06:07 AM MDT

Brian Foster

Good to know. Thank you.

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You need to include fresh vegetables and fruit in your diet.

Educate
06:08 AM MDT

Brian Foster

Good to know. Thank you.

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You also need to continue taking your medications as prescribed.

Educate
06:08 AM MDT

Brian Foster

Good to know. Thank you.

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You also need to wait yourself daily in the same clothes in the same time.

Educate
06:09 AM MDT

Brian Foster

Good to know. Thank you.

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You need to do light exercise has three to four times a week.

Educate
06:09 AM MDT

Brian Foster

Good to know. Thank you.

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Mister Foster you need to follow up with a primary care physician and a cardiologist.

Educate
06:10 AM MDT

Brian Foster

Good to know. Thank you.

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You also need to eliminate you alcoholic beverages.

Educate
06:11 AM MDT

Brian Foster

Good to know. Thank you.

 Model Statement: “I’m sorry you’re having these symptoms; chest pain can be uncomfortable and stressful. It’s good that you came in today so we can see what is causing your discomfort.”

 2 Hypertension and High Cholesterol
Followed Up

 Description: Mr. Foster describes his past medical history of hypertension and high cholesterol.

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When have you been diagnosed with hyperlipidemia ? (Clarified to: Are you diagnosed with high blood pressure?)

Question
02:52 PM MDT

Brian Foster

Yes, I supposedly have moderately high blood pressure. (Clarified to: if I have been diagnosed with hypertension)

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I’m sorry to hear that

Empathize
02:52 PM MDT

Brian Foster

Thanks. I appreciate that.

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She hasn’t been told that your cholesterol is always high ?

Question
06:29 AM MDT

Brian Foster

I’ve been told it’s moderately high. I’ve never noticed any actual symptoms from that though.

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Have you been tested for diabetes ?

Question
06:29 AM MDT

Brian Foster

My mom and my sister both have diabetes, but I don’t have it.

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Have you been monitoring your blood pressure ?

Question
06:29 AM MDT

Brian Foster

Not usually. They check it when I get checkups. My doctor has never seemed overly concerned about it.

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Do you remember your last blood pressure reading ? (Clarified to: Do you know your blood pressure number?)

Question
06:30 AM MDT

Brian Foster

No, not offhand. (Clarified to: if I know my blood pressure number)

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You need to monitor your blood pressure and you need to know your Baseline.

Educate
06:30 AM MDT

Brian Foster

Good to know. Thank you.

 Model Statement: “It’s good that I know you have been diagnosed with hypertension and high cholesterol, because those conditions can cause additional heart problems. I would like to find out more about your diagnosis and treatment of those conditions.”

 3 Exercise
Followed Up

 Description: Mr. Foster reports that he does not exercise regularly.

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Do you do exercise ?

Question
02:53 PM MDT

Brian Foster

Well I used to ride my bike a lot but it got stolen a couple years ago. I guess I haven’t had much regular exercise since then. I want to get a new bike if the doctor says it is OK to exercise with this chest pain I’ve been having.

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I’m sorry to hear that your bike was stolen

Empathize
02:53 PM MDT

Brian Foster

Thanks. I appreciate that.

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Do your exercise ?

Question
06:37 AM MDT

Brian Foster

Well I used to ride my bike a lot but it got stolen a couple years ago. I guess I haven’t had much regular exercise since then. I want to get a new bike if the doctor says it is OK to exercise with this chest pain I’ve been having.

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I’m sorry that chest pain makes you not exercise

Empathize
06:37 AM MDT

Brian Foster

Thanks. I appreciate that.

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Is it physical activity activates the pain ?

Question
04:53 AM MDT

Brian Foster

Well I used to ride my bike a lot but it got stolen a couple years ago. I guess I haven’t had much regular exercise since then. I want to get a new bike if the doctor says it is OK to exercise with this chest pain I’ve been having.

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Sorry to hear that

Empathize
04:53 AM MDT

Brian Foster

Thanks. I appreciate that.

 Model Statement: “Exercise is important for everyone, and particularly for people with high blood pressure and cholesterol. Let’s talk about some healthy forms of exercise that you would be interested in trying.”

 4 Diet
Followed Up

 Description: Mr. Foster describes his dietary habits.

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What type of food do you like ?

Question
02:54 PM MDT

Brian Foster

Um, let’s see . . . For breakfast I usually eat a granola bar and drink an instant breakfast shake. I’ve been doing that a while since it saves time in the morning. Most days for lunch I get a sandwich from the sub shop near work. That’s usually a turkey sub, but sometimes I get a spicy Italian sub. My wife and I grill a lot, and usually have some grilled meat with veggies for dinner.

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United include a lot of processed and fast food which is not good for your body. To have the same fast food diet may affect you over the time. You need to change your diet.

Educate
02:57 PM MDT

Brian Foster

Good to know. Thank you.

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You need to exercise.Not essential to do that with a bike. You can do sit ups, running or just simple indoor exercises in your home.

Educate
02:59 PM MDT

Brian Foster

Good to know. Thank you.

 Model Statement: “Paying attention to your diet is a great start. It’s best to make sure you’re eating veggies, fruits, and whole grains, and lean proteins like fish or chicken.”

 5 Weight Gain
Followed Up

 Description: Mr. Foster reports weight gain of 15 to 20 pounds in the last few years.

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Did you lose any weight? (Clarified to: Have you lost weight?)

Question
02:59 PM MDT

Brian Foster

Not exactly . . . I’ve gained about fifteen to twenty pounds in the last couple years. (Clarified to: if I have lost weight)

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It’s not good to gain the weight. You need to change the diet and start doing the exercises.

Educate
03:10 PM MDT

Brian Foster

Good to know. Thank you.

 Model Statement: “Gaining some weight over the years is very common. It’s a good idea to try to keep your weight in a healthy range. Things like moderate exercise and watching caloric intake can help keep you at a healthy weight.”

 6 Family History
Followed Up

 Description: Mr. Foster has a family history of heart disease.

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What’s what’s your fathers health ?

Question
03:14 PM MDT

Brian Foster

He really wasn’t doing so great in the last few years. He died when he was 75 of colon cancer, but even before that, his weight and his blood pressure and cholesterol were getting the best of him. It was rough. He didn’t last too long after the cancer diagnosis, unfortunately. I think he was tired of fighting.

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I’m sorry to hear that it should be very difficult to lose the father

Empathize
03:15 PM MDT

Brian Foster

Thanks. I appreciate that.

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How did you cope after you lost your father ?

Question
03:16 PM MDT

Brian Foster

Yeah. He died of colon cancer. He also had high blood pressure and high cholesterol.

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Sorry to hear that

Empathize
03:16 PM MDT

Brian Foster

Thanks. I appreciate that.

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Who’s your mother’s health ?

Question
03:16 PM MDT

Brian Foster

She has type 2 diabetes and some high blood pressure, but I think she’s doing pretty well for 80.

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Do you have a brothers and sisters ?

Question
03:17 PM MDT

Brian Foster

I have a sister, and I had a brother but he died many years ago.

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Sorry to hear that

Empathize
03:17 PM MDT

Brian Foster

Thanks. I appreciate that.

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How was your maternal grandmother ? (Clarified to: How is the health of your maternal grandmother?)

Question
03:17 PM MDT

Brian Foster

She had breast cancer. She was in her 60s when she died. (Clarified to: how my maternal grandmother’s health is)

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About maternal grandfather ?

Question
03:18 PM MDT

Brian Foster

My grandfather on my mom’s side died of a heart attack. He was in his mid-fifties.

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Sorry to hear that

Empathize
03:18 PM MDT

Brian Foster

Thanks. I appreciate that.

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How is your paternal grandfather ?

Question
03:18 PM MDT

Brian Foster

He was healthy right up until he died. He went in his sleep at 85, and we just called it old age.

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Sorry to hear that

Empathize
03:19 PM MDT

Brian Foster

Thanks. I appreciate that.

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Do you have any family history of heart attack ?

Question
06:46 AM MDT

Brian Foster

Well, my mom’s dad died of a heart attack. He was pretty young too.

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Do you have a family history of a stroke ?

Question
06:47 AM MDT

Brian Foster

No, none that I know of.

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Mr. Foster, Thank you for answering my questions now I’m going to do physical examination.

Educate
06:49 AM MDT

Brian Foster

Good to know. Thank you.

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Thank you Mr. Foster. I’m done with physical evaluation

Educate
07:30 AM MDT

Brian Foster

Good to know. Thank you.

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Mr.Foster how old are you ?

Question
04:13 AM MDT

Brian Foster

I’m 58 going on 30.

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Early happy birthday

Empathize
04:14 AM MDT

Brian Foster

Thanks. I appreciate that.

 Model Statement: “Thank you for sharing your family health information. It’s important that we know about any risk factors, so that you can make healthy choices to keep those risks low.”

Documentation / Electronic Health Record

Document: Vitals

Vitals
Blood Pressure 146/90
O2 Sat 98
Pulse 104
Resp. Rate 19
Temperature 36.7

Documentation / Electronic Health Record

Document: Provider Notes

Student Documentation Model Documentation

Subjective

Name Brian Foster. Patient is 58 y.o. male. Chief Complain : Chest Pain. Diagnosis: Stable angina pectoris. Mr. Foster notes that had that intermittent pain for a month located in mid-sternum. Patient describes the pain as heartburn which lasts only a couple of minutes and gives the sensation of the tightness in the chest. Patient mentioned that physical activity sometimes may aggravate the pain. He also notes that laying still helps to relieve the pain.

Past Medical History: Mr. Foster denies any surgical history. Past medical history included hypertension diagnosed 1 year ago and hyperlipidemia diagnosed 1 year ago.. Family History: Patients father died at the age of 75 from colon CA. His PMH was high blood pressure, high cholesterol, obesity and colon CA.

Mr Fosters mother is alive, she is 80 years old. Her PMH is Diabetes type 2, and high blood pressure. Patients brother is passed away at 24 y.o. from motorcycle accident. His sister is 52 years old. Her PMH is diabetes type 2 and high blood pressure…

Mr Foster has a healthy 26 y.o. son, and daughter 19 years old. She has an asthma. Social History : Mr Foster denies tobacco and illicit drug use. He admits drinking 2-3 alcoholic drinks per week. General : Mr Foster notes gaining 15-20 lbs over the last couple of years. No complains of fatigue or muscle weakness noted.

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Objective

BP 146/90, O2 Sat. 98% on RA, P 109, Respiratory Rate 19, Temp 36.7 orally Weight 197 lbs, Height 5.11, BMI 27.5 Patent is well appearing, friendly, well groomed with good maintained hygiene. No cognitive deficit noted. Patient is good historian in very pleasant mood. HEENT- pupils round, equal, brisk reactive to lights.

All mucous membranes are moist. Neck- No pain in the neck or limited ROM noted. Respiratory-lungs clear, with mild crackles on posterior lower lungs. Abdominal- No Surgical scars or distention noted. Cardiac-Mild tachycardia 109 Skin is dry and warm. No tenting found. examination. Face- no abnormality symmetrical.

Height of venous pressure 4 cm or less above the sternal angle. Chest is symmetrical. No visible and abnormal findings. Abdomen Symmetric No abnormal visible findings. Upper and lower extreemities- cyanosis noted. Negative to edema. Normal capillary refill, less than 3 seconds.

Auscultated carotid arteries positive for bruit bilateral. Auscultated heart sounds present S1-S2 sounds audible. Gallops presentation noted. Auscultation of the breath sounds present in all areas, fine crackles and adventitious sounds present bilaterally in posterior upper lobe bilaterally.

Auscultated abdominal aorta showing no bruit. Auscultated abdominal and lower extremity arteries negative for bruit in bilaterally in renal illiac and femoral arteries. No friction rub present upon auscultation of spleen and liver. Ausculcated bowel sounds are normoactive in all four quadrants.

Palpitation of carotid arteries showing on the right side thrill with +3 increased amplitude. On the left side no thrill present with +2 expected amplitude. Palpated PMI displaced laterally. Brisk and tapping amplitude is less than 3 cm. Palpated Brachial arteries showing no thrill on the right side with amplitude +2 as expected. On the left side +2 expected amplitude.

Palpated radial arteries presenting no thrill on the right side with +2 expected amplitude. On the left side there is no thrill as well with +2 expected amplitude. Palpated femoral arteries showing no thrill bilaterally with +2 expected amplitude. Palpation of popliteal, dorsalis pedis and tibial arteries indicated no thrill and +1 diminished or barely palpable amplitude bilaterally.

Palpation of abdomen is normal no tenderness, mass or other abnormality present.Liver is palpable. Spleen is not palpable. Bilateral kidneys not palpable. Skin not tenting. Percussed abdomen showing that generally all abdominal quadrants as well as spleen are tympanic. Percussed liver size showing between 6and 12 cm.

N/A

Assessment

Patient is generally good looking, well appearing, maintains good hygiene. Good historian no cognitive deficit note. Alert oriented to person, place, time, situation. Neck: No pain, no restrictive movements or jugular vein distention noted. JVD is 3 cm above the sternal angle. A bruit is auscultated in the right carotid artery with positive thrill and amplitude of 3+No bruit found in the left carotid artery with no thrill and amplitude of 2+

Thorax: Maximum impulse found to be displaced laterally with brisk tapping and diameter of less than 3 cm. Respiratory: Lungs sounds are clear bilterally, anterior and posterior upper fields. Fine crackles heard bilaterally in posterior lower lung fields.

Abdomen: Abdominal aorta free of bruits. No tenderness or massess noted on palpation. The liver is palpable. Spleen is not palpable. Right and left kidneys are not palpable. EKG performed and showed that patient has Normal Sinus Rhythm with no ST elevation. Periferall vascular : 1+tibial and DP pulses found bilaterally.1+popliteal pulses noted bilaterally with no thrill. 2+femoral and radial pulses noted bilaterally.

Varicosites noted in bilateral lower extremities with minimal swelling and cyanosis. Mr Fosters chest pain related to his obesity and luck of exercise. He also consumes excessive amount red meat which may also can be related to high cholesterol condition.

N/A

Plan

Diagnosis :Exertional chest pain relieved by rest. Stable Angina Pectoris. Diagnostics: Echocardiogram and stress test. Pharmacology: Continue current prescribed medications: Lopressor 100 mg PO Daily. Lipitor 20 mg PO Daily for high cholesterol Fish oil 1200 mg PO BID for managing heart disease. Start patient for new course of Nitroglycerin for chest pain episodes.

Education/Counselling: Proper and routine monitoring weight, cardiac markers and lipid level. Patient will be instructed to change in diet and lifestyle includig the light exercise 3-4 times per week. Patient will be instructed to cut the red meat and include more chicken and fish in diet as well as more food with fiber such as fresh fruits, vegetables.

Changes in diet and exercise will require for adjustment in medications. Referrals: Mr.Foster will be referred to cardiologist consultation for further evaluation. Patient will most likely required for further heart cathetherization with possible admission to the hospital with pre-procedure and post-procedure ECG monitoring and routine labwork.

Follow up : Patient is to follow up with cardiologist within 2 days. To schedule the follow up appointment within 3-4 days. Mr. Foster were performed adequate and detailed health history and physical examination. The assessment was concentrated in Chief complain and rule out GI symptoms, which was not related in this particular case.His treatment plan reflects the current chief complain inclusing objective and subjective result.

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